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History: 76-year-old male with severe mitral insufficiency, pulmonary arterial hypertension, acute dyspnea Case of the Month 3 September 2015 Authors: Paola Franchi Anna Rit 9 th Jan 2013

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Page 1: History : 76-year-old male with severe mitral insufficiency, pulmonary arterial hypertension, acute dyspnea Case of the Month 3 September 2015 Authors:

History: 76-year-old male with severe mitral insufficiency, pulmonary arterial hypertension, acute dyspnea

Case of the Month 3September 2015

Authors: Paola Franchi Anna Rita Larici

9th Jan 2013

Page 2: History : 76-year-old male with severe mitral insufficiency, pulmonary arterial hypertension, acute dyspnea Case of the Month 3 September 2015 Authors:

Case of the Month 3 11th Jan 2013

Page 3: History : 76-year-old male with severe mitral insufficiency, pulmonary arterial hypertension, acute dyspnea Case of the Month 3 September 2015 Authors:

11th Jan 2013

Case of the Month 3

Page 4: History : 76-year-old male with severe mitral insufficiency, pulmonary arterial hypertension, acute dyspnea Case of the Month 3 September 2015 Authors:

30th Jan 2013Case of the Month 3

Page 5: History : 76-year-old male with severe mitral insufficiency, pulmonary arterial hypertension, acute dyspnea Case of the Month 3 September 2015 Authors:

30th Jan 2013

Case of the Month 3

Page 6: History : 76-year-old male with severe mitral insufficiency, pulmonary arterial hypertension, acute dyspnea Case of the Month 3 September 2015 Authors:

Case of the Month 3Diagnosis

What is your diagnosis ?

Page 7: History : 76-year-old male with severe mitral insufficiency, pulmonary arterial hypertension, acute dyspnea Case of the Month 3 September 2015 Authors:
Page 8: History : 76-year-old male with severe mitral insufficiency, pulmonary arterial hypertension, acute dyspnea Case of the Month 3 September 2015 Authors:

History: 76-year-old male with severe mitral insufficiency, pulmonary arterial hypertension, acute dyspnea

Question: Which are the abnormalities on this chest X-ray?

Case of the Month 3September 2015

Authors: Paola Franchi Anna Rita Larici

9th Jan 2013

Page 9: History : 76-year-old male with severe mitral insufficiency, pulmonary arterial hypertension, acute dyspnea Case of the Month 3 September 2015 Authors:

Alveolar opacity in the right parahilar region with air bronchogram (arrows)

Case of the Month 3

Page 10: History : 76-year-old male with severe mitral insufficiency, pulmonary arterial hypertension, acute dyspnea Case of the Month 3 September 2015 Authors:

The opacity is predominantly located in the right upper lobe (RUL)

Case of the Month 3

Page 11: History : 76-year-old male with severe mitral insufficiency, pulmonary arterial hypertension, acute dyspnea Case of the Month 3 September 2015 Authors:

Case of the Month 3

Thickening of the minor fissure

Page 12: History : 76-year-old male with severe mitral insufficiency, pulmonary arterial hypertension, acute dyspnea Case of the Month 3 September 2015 Authors:

Enlargement of the pulmonary arterial vessels

Case of the Month 3

Page 13: History : 76-year-old male with severe mitral insufficiency, pulmonary arterial hypertension, acute dyspnea Case of the Month 3 September 2015 Authors:

Cardiomegaly

Case of the Month 3

Predominantly of the left heart chambers

Page 14: History : 76-year-old male with severe mitral insufficiency, pulmonary arterial hypertension, acute dyspnea Case of the Month 3 September 2015 Authors:

Aortic dilation

Case of the Month 3

Page 15: History : 76-year-old male with severe mitral insufficiency, pulmonary arterial hypertension, acute dyspnea Case of the Month 3 September 2015 Authors:

Question: What is shown on the CT images?

Case of the Month 3 11th Jan 2013

Page 16: History : 76-year-old male with severe mitral insufficiency, pulmonary arterial hypertension, acute dyspnea Case of the Month 3 September 2015 Authors:

Case of the Month 3

GGO with air bronchogram mainly located in the RUL

Relative sparing of the subpleural areas

11th Jan 2013

Page 17: History : 76-year-old male with severe mitral insufficiency, pulmonary arterial hypertension, acute dyspnea Case of the Month 3 September 2015 Authors:

Question: Some days later… what is shown on the CT images?

Case of the Month 3 30th Jan 2013

Page 18: History : 76-year-old male with severe mitral insufficiency, pulmonary arterial hypertension, acute dyspnea Case of the Month 3 September 2015 Authors:

Case of the Month 3

Areas of GGO in the RUL

Smooth interlobular septal thickening in the RUL

30th Jan 2013

Page 19: History : 76-year-old male with severe mitral insufficiency, pulmonary arterial hypertension, acute dyspnea Case of the Month 3 September 2015 Authors:

Case of the Month 3

Bilateral pleural effusion, greater on the right

30th Jan 2013

Page 20: History : 76-year-old male with severe mitral insufficiency, pulmonary arterial hypertension, acute dyspnea Case of the Month 3 September 2015 Authors:

Question: Which information adds the use of the contrast medium?

Case of the Month 3 30th Jan 2013

31 mm

Page 21: History : 76-year-old male with severe mitral insufficiency, pulmonary arterial hypertension, acute dyspnea Case of the Month 3 September 2015 Authors:

Case of the Month 3

31 mm

Pulmonary artery dilatation

Reflux of contrast medium in the IVC and hepatic veins due to cardiac ovreload

Page 22: History : 76-year-old male with severe mitral insufficiency, pulmonary arterial hypertension, acute dyspnea Case of the Month 3 September 2015 Authors:

Case of the Month 3

28th Feb 201320th Feb 2013

… after mitral valve replacementBefore and…

Page 23: History : 76-year-old male with severe mitral insufficiency, pulmonary arterial hypertension, acute dyspnea Case of the Month 3 September 2015 Authors:

Case of the Month 3Diagnosis

Unilateral Pulmonary Edema secondary to severe mitral

valve regurgitationDifferential Diagnosis - Pulmonary infection- Alveolar hemorrhage- Carcinomatous lymphangitis- Aspiration pneumonitis

Page 24: History : 76-year-old male with severe mitral insufficiency, pulmonary arterial hypertension, acute dyspnea Case of the Month 3 September 2015 Authors:

Case of the Month 3Discussion

Cardiogenic unilateral pulmonary edema (UPE) is a rare entity, frequently leading to initial misdiagnosis

UPE represents about 2.1% of cardiogenic pulmonary edema

UPE is always associated with severe mitral regurgitation

UPE is related to an independent increased risk of mortality and should be promptly recognized to avoid delays in treatment

Page 25: History : 76-year-old male with severe mitral insufficiency, pulmonary arterial hypertension, acute dyspnea Case of the Month 3 September 2015 Authors:

Case of the Month 3Discussion

Left ventricle, mitral valve, left atrium, right superior pulmonary vein, and the RUL are aligned along the path expected for a regurgitant jet caused by mitral insufficiency, with a resulting increase in hydrostatic pressure in the right superior pulmonary vein

Asymmetric pulmonary edema concentrated in the right upper lobe is typically associated with mitral regurgitation resulting from a flail posterior leaflet, which can be caused by rupture of the chordae tendineae or papillary muscle

Page 26: History : 76-year-old male with severe mitral insufficiency, pulmonary arterial hypertension, acute dyspnea Case of the Month 3 September 2015 Authors:

Case of the Month 3Discussion

CHEST RADIOGRAPHY Loss of definition of segmental and subsegmental

vessels Enlargement of peribronchovascular spaces and

peribronchial cuffing Kerley lines Areas of increased opacity Pleural effusion All findings are more conspicuous on the right

HIGH-RESOLUTION CT Ground-glass opacity Smooth interlobular septal thickening Peribronchovascular interstitial thickening Increased vascular diameter Pleural effusion All findings are more conspicuous in the RUL

Page 27: History : 76-year-old male with severe mitral insufficiency, pulmonary arterial hypertension, acute dyspnea Case of the Month 3 September 2015 Authors:

Case of the Month 3Further Reading

UNILATERAL PULMONARY EDEMA DUE TO MITRAL VALVE REGURGITATION1) Gurney JW, Goodman LR. Pulmonary edema localized in the right upper lobe accompanying mitral regurgitation Radiology 1989;171:397-92) Alarcón JJ et al. Localized right upper lobe edema Chest 1995;107:274-63) Raman S, Pipavath S. Images in clinical medicine. Asymmetric edema of the upper lung due to mitral valvular dysfunction N Engl J Med 2009;361:e64) Attias D et al. Prevalence, characteristics, and outcomes of patients presenting with cardiogenic unilateral pulmonary edema. Circulation 2010;122:1109-155) Bagate F et al. Febrile unilateral pulmonary edema: a potential misdiagnosis Int J Cardiol 2014;174:867-86) Bishara H et al. An 80-year-old man with a right upper lobe opacity Clin Respir J 2015 doi: 10.1111/crj.12293

Page 28: History : 76-year-old male with severe mitral insufficiency, pulmonary arterial hypertension, acute dyspnea Case of the Month 3 September 2015 Authors:

Case of the Month 3Diagnosis

Unilateral Pulmonary Edema

Differential Diagnosis - Pulmonary infection- Alveolar hemorrhage- Carcinomatous lymphangitis- Aspiration pneumonitis

Page 29: History : 76-year-old male with severe mitral insufficiency, pulmonary arterial hypertension, acute dyspnea Case of the Month 3 September 2015 Authors:

Case of the Month 3Discussion

Cardiogenic unilateral pulmonary edema (UPE) is a rare entity, frequently leading to initial misdiagnosis

UPE represents about 2.1% of cardiogenic pulmonary edema

UPE is always associated with severe mitral regurgitation

UPE is related to an independent increased risk of mortality and should be promptly recognized to avoid delays in treatment

Page 30: History : 76-year-old male with severe mitral insufficiency, pulmonary arterial hypertension, acute dyspnea Case of the Month 3 September 2015 Authors:

Case of the Month 3Discussion

Left ventricle, mitral valve, left atrium, right superior pulmonary vein, and the RUL are aligned along the path expected for a regurgitant jet caused by mitral insufficiency, with a resulting increase in hydrostatic pressure in the right superior pulmonary vein

Asymmetric pulmonary edema concentrated in the right upper lobe is typically associated with mitral regurgitation resulting from a flail posterior leaflet, which can be caused by rupture of the chordae tendineae or papillary muscle

Page 31: History : 76-year-old male with severe mitral insufficiency, pulmonary arterial hypertension, acute dyspnea Case of the Month 3 September 2015 Authors:

Case of the Month 3Discussion

CHEST RADIOGRAPHY Loss of definition of segmental and subsegmental

vessels Enlargement of peribronchovascular spaces and

peribronchial cuffing Kerley lines Areas of increased opacity Pleural effusion All findings are more conspicuous on the right

HIGH-RESOLUTION CT Ground-glass opacity Smooth interlobular septal thickening Peribronchovascular interstitial thickening Increased vascular diameter Pleural effusion All findings are more conspicuous in the RUL

Page 32: History : 76-year-old male with severe mitral insufficiency, pulmonary arterial hypertension, acute dyspnea Case of the Month 3 September 2015 Authors:

Case of the Month 3Further Reading

UNILATERAL PULMONARY EDEMA DUE TO MITRAL VALVE REGURGITATION1) Gurney JW, Goodman LR. Pulmonary edema localized in the right upper lobe accompanying mitral regurgitation Radiology 1989;171:397-92) Alarcón JJ et al. Localized right upper lobe edema Chest 1995;107:274-63) Raman S, Pipavath S. Images in clinical medicine. Asymmetric edema of the upper lung due to mitral valvular dysfunction N Engl J Med 2009;361:e64) Attias D et al. Prevalence, characteristics, and outcomes of patients presenting with cardiogenic unilateral pulmonary edema. Circulation 2010;122:1109-155) Bagate F et al. Febrile unilateral pulmonary edema: a potential misdiagnosis Int J Cardiol 2014;174:867-86) Bishara H et al. An 80-year-old man with a right upper lobe opacity Clin Respir J 2015 doi: 10.1111/crj.12293


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